Chapter 086. Breast Cancer (Part 8)

Table 86-3 Suggested Approaches to Adjuvant TherapyAge Group hLympEndocrTum tionRecommendaNode ine Receptor or (ER) StatusStatusaPremenopa usal vePositiAnyAnyMultidrug chemotherapy tamoxifen positive if + ER+trastuzumab in HER-2/neu tumorspositivePremenopa usal iveNegatAny2Multidrug + ER+cm, or 1–2 chemotherapy cm with tamoxifen ifother poor positiveprognostic trastuzumab in HERvariables 2/neu tumors positivePostmenopa usal vePositi eNegativAnyMultidrug chemotherapy +trastuzumab in HER2/neu tumors positivePostmenopa usal vePositiPositiveAnyAromatase inhibitors andtamoxifen with or withoutchemotherapy+trastuzumab in HER2/neu tumors positivePostmenopa usal iveNegatPositive2Aromatase and +cm, or 1–2 inhibitors cm with tamoxifenother poor trastuzumab in HERprognostic 2/neu variables tumors positivePostmenopa usal iveNegat eNegativ2Consider ...
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Chapter 086. Breast Cancer (Part 8) Chapter 086. Breast Cancer (Part 8) Table 86-3 Suggested Approaches to Adjuvant Therapy Age Group Lymp Endocr Tum Recommenda h Node ine Receptor or tion Statusa (ER) Status Premenopa Positi Any Any Multidrugusal ve chemotherapy + tamoxifen if ER- positive + trastuzumab in HER- 2/neu positive tumors Premenopa Negat Any >2 Multidrugusal ive cm, or 1–2 chemotherapy + cm with tamoxifen if ER- other poor positive + prognostic trastuzumab in HER- variables 2/neu positive tumors Postmenopa Positi Negativ Any Multidrugusal ve e chemotherapy + trastuzumab in HER- 2/neu positive tumors Postmenopa Positi Positive Any Aromataseusal ve inhibitors and tamoxifen with or without chemotherapy + trastuzumab in HER- 2/neu positive tumors Postmenopa Negat Positive >2 Aromataseusal ive cm, or 1–2 inhibitors and cm with tamoxifen + other poor trastuzumab in HER- prognostic 2/neu positive variables tumors Postmenopa Negat Negativ >2 Considerusal ive e cm, or 1–2 multidrug cm with chemotherapy + other poor trastuzumab in HER- prognostic 2/neu positive variables tumors a As determined by pathologic examination. Data on postmenopausal women are also controversial. The impact ofadjuvant chemotherapy is quantitatively less clear-cut than in premenopausalpatients, although survival advantages have been shown. The first decision iswhether chemotherapy or endocrine therapy should be used. While adjuvanttamoxifen improves survival regardless of axillary lymph node status, theimprovement in survival is modest for patients in whom multiple lymph nodes areinvolved. For this reason, it has been usual to give chemotherapy topostmenopausal patients who have no medical contraindications and who havemore than one positive lymph node; tamoxifen is commonly given simultaneouslyor subsequently. For postmenopausal women for whom systemic therapy iswarranted but who have a more favorable prognosis, tamoxifen may be used as asingle agent. Large clinical trials have shown superiority for aromatase inhibitorsover tamoxifen alone in the adjuvant setting. Unfortunately the optimal plan isunclear. Tamoxifen for 5 years followed by an aromatase inhibitor, the reversestrategy, or even switching to an aromatase inhibitor after 2–3 years of tamoxifenhas been shown to be better than tamoxifen alone. No valid information currentlypermits selection among the three clinically approved aromatase inhibitors. Largeclinical trials currently underway will help address these questions. Most comparisons of adjuvant chemotherapy regimens show littledifference among them, although small advantages for doxorubicin-containingregimens are usually seen.